Current Issues in Hand Hygiene John M. Boyce, MD J.M. Boyce - - PowerPoint PPT Presentation

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Current Issues in Hand Hygiene John M. Boyce, MD J.M. Boyce - - PowerPoint PPT Presentation

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Current Issues in Hand Hygiene John M. Boyce, MD J.M. Boyce Consulting, LLC Middletown, CT Disclosures: JMB is a consultant to Diversey, Global Life Technologies Corp and GOJO Industries 1 Topics for Discussion How long should healthcare

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Current Issues in Hand Hygiene

John M. Boyce, MD J.M. Boyce Consulting, LLC Middletown, CT

Disclosures: JMB is a consultant to Diversey, Global Life Technologies Corp and GOJO Industries

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Topics for Discussion

  • How long should healthcare personnel (HCP) perform hand hygiene with

alcohol-based hand rubs (ABHR)?

  • Does hand size affect the volume of ABHR that should be applied?
  • What is appropriate hand hygiene technique?
  • What methods for promoting improved hand hygiene work?
  • Current approaches to monitoring hand hygiene performance

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What is the Appropriate Application Time (Duration)

  • f Hand Hygiene Using an Alcohol-Based Hand Rub (ABHR)?
  • 2002 CDC Hand Hygiene guideline
  • Recommends applying product to a palm, rub hands together, and cover all surfaces of

hands and fingers

  • No specific duration recommended
  • Text states that if hands feel dry after rubbing together for 10-15 seconds, an insufficient

volume of product has likely been applied

  • 2009 WHO Hand Hygiene guideline
  • Recommends that hands be rubbed together for
  • 20-30 seconds when using an ABHR
  • 40-60 seconds when washing with soap & water
  • WHO 6-step technique for ABHR disinfection requires even longer duration
  • Time to complete 6-step procedure in several studies: 38.5 – 42.5 seconds

Chow A et al. Am J Infect Control 2012’40:800 Reilly JS et al. Infect Control Hosp Epidemiol 2016;37:661

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HCP Hand Hygiene Practices: Duration and Preferred Volume

  • Ward-based surveys of duration of alcohol-based hand antisepsis
  • Median time to rub hands until they feel dry (dry times): 4 sec – 11 sec
  • Mean time to rub hands until they feel dry: 6 sec – 15.3 sec
  • HCP prefer small volumes that yield short dry times
  • In two studies that permitted HCP choose volume to apply,

mean volume per application ranged from 0.73 ml – 1.09 ml

  • In observational study in Scotland, mean volume per application was 1 ml

Helder OK et al. Int J Nurs Studies 2010;47:1245 Reardon JM et al. Infect Control Hosp Epidemiol 2013;34:96 Korhonen A et al. J Clin Nurs 2015;24:3197 Stahmeyer JT et al. J Hosp Infect 2017;95:338 Clack L et al. Antimicrob Resist Infect Control 2017;6:108 Leslie RA et al. Antimicrob Resist Infect Control 2015;4(Suppl 1):295 Martinello RA et al. SHEA Spring Conference 2017, Abstr. 445 Dalziel C et al. J Hosp Infect 2018;98:375

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Factors Affecting the Duration of Hand Hygiene with ABHR

  • Factors affecting how long HCP need to rub their hands together before they feel dry
  • Volume applied is the major factor
  • The greater the amount applied, the longer the dry time
  • Amount delivered by dispensers is variable (0.7 ml to 1.75 ml)
  • Product formulation is another important factor
  • Applying same amount of two different products may yield significantly different dry times
  • Higher alcohol concentrations yield faster dry times
  • Other product ingredients can also affect dry times
  • Recommendation
  • With most products, if an adequate amount of ABHR has been applied, hands shouldn’t

feel dry until they have been rubbed together for 15 – 30 seconds

Girard R et al. J Epidemiol Global Health 2013;2:193 Macinga DR et al. Infect Control Hosp Epidemiol 2013;34:299 Macinga DR et al. BMC Infect Dis 2014;14:511 Pires D et al. Infect Control Hosp Epidemiol 2017;38:547 Wilkinson MA et al. J Hosp Infect 2017;95:175

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Should the Volume of Alcohol-Based Hand Rub Applied Be Based on Healthcare Worker Hand Size?

  • Goroncy-Bermes et al. reported in 2010
  • Microbicidal efficacy of ABHRs was affected by size of HCP hands and volume applied
  • Type of product also affected log10 reductions of bacteria achieved
  • Bellissimo-Rodrigues et al. found:
  • Log10 reductions of bacteria were significantly lower for large hands compared to small hands
  • Even 3 ml of ABHR applied for 30 second did not yield 2 log10 reduction in HCP with large hands
  • In a study of 67 HCP, even 3 ml of ABHR was not enough to cover all surfaces of those

with medium- or large-sized hands

  • Method of assessing hand coverage seems open to question

Goroncy-Bermes et al. J Hosp Infect 2010;74:212 Bellissimo-Rodrigues F et al. Infect Control Hosp Epidemiol 2016;37:219 Zingg W et al. Am J Infect Control 2016;44:1689

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Should the Volume of Alcohol-Based Hand Rub Applied Be Based on Healthcare Worker Hand Size?

  • In a prospective study of 53 nurses on several wards, each nurse was

given a special bottle of ABHR on each of 3 shifts

  • Each nurse could choose the volume of ABHR to apply to their hands
  • Bottle cap counted number of times bottle was opened during a shift
  • Amount of ABHR used by each nurse was determined for each shift
  • Volume of ABHR used/shift

Number of times bottle was opened/shift

  • Nurses’ hand sizes were measured and surface area estimated
  • Results
  • Mean volume of ABHR used/application was 1.09 ml (95% range: 0.19-2.3)
  • No significant correlation between hand size and volume of ABHR applied
  • Most variation in volume used/application was between individual nurses,

and less due to differences between wards Martinello RA et al. SHEA Spring Conference 2017, Abstr. 445 = mean volume per application

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Should the Volume of Alcohol-Based Hand Rub Applied Be Based on Healthcare Worker Hand Size?

  • A given dose of ABHR will not provide
  • Same degree of coverage of all hand surfaces in HCP with small vs large hands
  • Same efficacy in reducing bacterial contamination of different-sized hands
  • Volume of ABHR delivered by dispensers may be considered “too much” by nurses with small

hands, but be insufficient for those with large hands

  • Conclusion
  • Efforts to design ABHR dispensers that individualize dose delivered/application are warranted
  • Dose should be adequate to cover all surfaces of hands, and keep hands wet long enough to

achieve desired log10 reductions

  • Possible methods for individualizing the dose of ABHR applied to hands
  • Rapid scan & estimation of hand size when hand placed under dispenser, with dose based on hand size
  • Encoding hand size in electronic badges worn by HCP; dispenser recognizes HCW and delivers appropriate dose

Bellissimo-Rodrigues F et al. Infect Control Hosp Epidemiol 2016;37:219 Zingg W et al. Am J Infect Control 2016;44:1689 Kampf G Infect Control Hosp Epidemiol 2017 (Epub ahead of print)

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Recommended Hand Hygiene Technique

  • 2002 CDC Guideline
  • Apply ABHR to palm of one hand and rub hands

together, covering all surfaces of hands and fingers, until hands are dry

  • 2009 WHO Guideline
  • Apply palmful of ABHR and cover all surfaces of

the hands. Rub hands until dry

  • Duration of the entire procedure: 20-30 seconds

seconds

  • Recommended a 6-step procedure
  • Compliance with complicated 6-step

procedure has varied from 0% to 8.5%

Stewardson AJ et al. PLoS One 2014;9:e105866 Tschudin-Sutter S et al. Infect Control Hosp Epidemiol 2015;36:48

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WHO 6-Step vs Simplified 3-Step Hand Hygiene Technique

  • 2 randomized, controlled trials compared the 3-step CDC method to 6-step WHO method
  • One study: no significant difference in the effectiveness of the 2 methods
  • One study: the WHO method was more effective
  • One study found the WHO 6-step method required 42.5 seconds vs 35 seconds for the CDC

method

  • Video camera-based device with immediate feedback was used for self-directed check on

compliance with the 6-step technique

  • Use of the device increased the number of steps completed, but did not result in HCP completing all 6

steps in one study

  • In another study, HCP frequently missed one or more of the 6 steps
  • HCP liked the automated device
  • Its effect on ward-based hand hygiene technique was not assessed
  • Hand hygiene compliance rates did not increase

Price L et al. Am J Infect Control 2018; Reilly JS et al. Infect Control Hosp Epidemiol 2016;37:661 Stewardson AJ et al. PLoS One 2014;9:e105866 Kwok YL et al. Am J Infect Control 2015;43:821

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Hand Hygiene Technique

  • Kampf et al. found that instructing HCWs to

cover both hands completely, without providing any specific steps “responsible application” was as effective a 6-step method

  • Tschudin-Sutter proposed a simplified 3-step

method

  • Modified 3-step method was more effective

microbiologically than WHO method

  • Conclusion
  • Modified 3-step method is easier and quicker

than 6-step method, is effective, and should be considered for adoption

Kampf G et al. BMC Infect Dis 2008;8:149 Tschudin-Sutter S et al. Clin Microbiol Infect 2017;23:409

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The Five Components of the WHO multimodal hand hygiene improvement strategy (WHO-5)

  • 1a. System change –

Alcohol-based handrub at point of care

  • 1b. System change – access to safe,

Continuous water supply, soap and towels

  • 2. Training and education
  • 3. Evaluation and feedback
  • 4. Reminders in the workplace

+ + + + +

  • 5. Institutional safety climate

www.who.int/gpsc/5may/tools/training_education/en/

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Essential Elements for Improving Hand Hygiene

  • Making alcohol-based hand rub available at the point of care
  • Evidence favors locating dispensers in hallways and in patient rooms
  • Consider pocket-sized bottles in areas with few locations for dispensers (e.g., ER)
  • Educate, then re-educate
  • E.g., mandatory, annual on-line learning sessions
  • Performance feedback
  • Quarterly or monthly feedback has questionable impact
  • Just-in-time coaching, providing verbal reminders1,2
  • By designated individuals
  • Peers on nursing units
  • Weekly feedback reports or real-time displays on nursing units
  • Emails to nurse/department managers or text messages to front-line HCWs3,4

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1Chassin MR et al. Jt Comm J Qual Patient Saf 2015;41:13 2Sickbert-Bennett et al. Emerg Infect Dis 2016;22:1628 3Armellino D et al, Clin Infect Dis 2012;54:1 4Kerbaj J et al. Am J Infect Control 2017;45:234

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Essential Elements for Improving Hand Hygiene

  • Reminders in the workplace
  • Screen saver messages on unit computer displays
  • Signs (based on cognitive biases) next to dispensers1
  • Visible and vocal support from administration
  • Reports and discussion at high-level board & committee meetings
  • Providing adequate resources for hand hygiene promotion
  • Efforts to improve institutional safety climate2,3
  • “Do No Harm” programs
  • High-Reliability Organization (HRO) initiatives

14 1Caris MG et al. J Hosp Infect 2018;98:352 2Caris MG Infect Control Hosp Epidemiol 2017;38:1277 3Wolfe JD et al. J Patient Saf 2018 (Epub ahead of print)

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Efficacy of Different Intervention Strategies in Improving Hand Hygiene

  • Systematic review and meta-analysis of hand hygiene
  • 41 of 3639 studies retrieved were included in the analysis
  • 6 randomized controlled trials
  • 32 interrupted time series studies
  • 1 non-randomized trial
  • 2 controlled before/after trials
  • Meta-analysis of 2 randomized controlled trials revealed that

adding goal setting to WHO-5 yielded improved compliance

  • Of 22 pairwise comparisons of interrupted time series, 18 showed

stepwise improvement in hand hygiene compliance

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Luangasanatip N et al. BMJ 2015;351:h3728

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Efficacy of Hand Hygiene Promotional Strategies

  • WHO-5 was effective in improving hand hygiene
  • Compliance can be further improved by adding other strategies
  • Goal setting
  • Set institutional or unit-based goals for compliance rates
  • Reward incentives
  • Rotating trophy for unit with best compliance rate
  • Pizza or other food parties for unit with highest compliance
  • Institution-wide employee bonus if compliance goals met
  • Accountability
  • Peer-to-peer observations and reminders
  • “200% accountability”
  • Administrator/dept chair feedback to recalcitrant physicians
  • Short, mandatory weekly meetings of nursing unit representatives

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Luangasanatip N et al. BMJ 2015;351:h3728 Sickbert-Bennett E et al. Emerg Infect Dis 2016;22:1628 Harold J et al. IDSA Annual Meeting, 2007, Abstr. 566 Landon EL et al. IDSA Annual Meeting, 2017, Abstr. 151

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Approaches to Monitoring Hand Hygiene Compliance

  • Direct observations by expert observers
  • Direct observations by patients
  • Consumption of hygiene products (e.g., ABHR, soap)
  • Automated monitoring systems
  • Require limited personnel time after installation
  • Continuously monitor hand hygiene opportunities and events
  • Record many more opportunities and events than by direct
  • bservation

Yin J et al. Infect Control Hosp Epidemiol 2014;35:1163 Marra AR et al. Clin Microbiol Infect 2014;20:29 Ward MA et al. Am J Infect Control 2014;42:472 Srigley JA et al. J Hosp Infect 2015;89:51 Boyce JM Am J Infect Control 2017;45:528

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Direct Observation by Trained Observers

  • Direct observation of personnel by trained observers is currently

considered the “gold standard” method of determining hand hygiene compliance rates

  • Advantages
  • Determine compliance with all 5 Moments for Hand Hygiene
  • Evaluate hand hygiene technique
  • Provide immediate feedback to healthcare personnel
  • Limitations
  • Lack of standardized methods
  • Evaluates < 1% to 2% of all hand hygiene opportunities
  • Hawthorne effect (personnel improve compliance when being watched)
  • Time-consuming

Ward MA et al. Am J Infect Control 2014;42:472 Boyce JM Am J Infect Control 2017;45:528 Srigley JA et al. BMJ Qual Saf 2014;23:974

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Electronic Monitoring of Product Usage

  • Electronic devices placed inside dispensers can record

each time the dispenser is accessed (HH event)

  • HH events are time/date stamped
  • HH Event data can be downloaded for subsequent analysis
  • Can establish trends in hand hygiene frequency over time
  • Limitations
  • Cannot tell who used dispensers (HCW, visitors, patients)
  • Does not give information on hand hygiene compliance

Larson EL et al. Am J Crit Care 2005;14:304 Boyce JM et al. Infect Control Hosp Epidemiol 2009;30:1090 Marra AR et al. Infect Control Hosp Epidemiol 2010;31:796 Sodre da Costa LS Am J Infect Control 2013;41:997 Filho MA et al. Am J Infect Control 2014;42:1188 Arai A et al. Am J Infect Control 2016;44:1481

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Automated Monitoring of Product Usage

  • Automated system for monitoring of hand hygiene (HH) events

+ estimated number of HH opportunities

  • Dispensers record electronically each time the dispenser is accessed (HH

event) and send data to computer server

  • HH opportunities can be estimated based patient census, patient-to-nurse

ratio, and adjustments

  • HH compliance is estimated by software
  • # of HH events

= estimated compliance # of estimated opportunities

  • Further studies of validity in additional settings are warranted

Steed C et al. Am J Infect Control 2011;39:19 Diller T et al. Am J Infect Control 2014;42:602 Conway et al. Jt Comm J Qual Pat Saf 2014;40:408 Kwok YL et al. Am J Infect Control 2016;44:1475

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Automated Group Monitoring and Feedback Systems

  • More complex electronic systems with
  • Counting devices in dispensers, and
  • Sensors detect persons entering/exiting patient rooms
  • Can estimate hand hygiene compliance of groups of personnel
  • Dispensers record hand hygiene events
  • Room entry = proxy for Moment 1; exit = proxy for Moments 4 & 5
  • # of Events / # of room entries & exits = estimated compliance
  • Provide real-time feedback to groups of healthcare personnel (HCP)
  • Limitations:
  • Cannot tell if persons entering room are HCP or not
  • Do not provide data on compliance with Moments 2 and 3

Swoboda SM et al. Crit Care Med 2004;32:358 Ellison RT et al. Open Forum Infect Dis 2015;2:0vf121 Limper HM et al. Infect Control Hosp Epidemiol 2017;38:348

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Automated Badge-Based Monitoring Systems

  • Advantages
  • Provide healthcare worker-specific compliance rates
  • Some systems can provide real-time reminders to HCWs
  • Provide real-time visual, auditory or vibratory reminders
  • Limitations
  • More expensive and complicated than other systems
  • Some systems currently have suboptimal accuracy in detecting hand hygiene opportunities and events
  • Acceptance by HCWs has been a problem with some systems
  • Most systems cannot estimate compliance with all 5 Moments for hand hygiene
  • Further information is also needed on:
  • Ability to improve hand hygiene compliance rates in a sustained manner
  • Impact on healthcare-associated infection rates and cost-effectiveness
  • How to best combine automated monitoring systems with direct observations in multimodal strategy

Marra AR et al. Clin Microbiol Infect 2014;20:29 Ward MA et al. Am J Infect Control 2014;42:472 Srigley JA et al. J Hosp Infect 2015;89:51 Boyce JM Am J Infect Control 2017;45:528

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Qu Ques esti tions?

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Hand Hygiene Technique Among HCWs

  • Study involved 60 healthcare workers
  • Methods

– Hand cultures were obtained before/after hand antisepsis using ABHR + fluorescent dye – 5 areas on hands were checked for contact with ABHR

  • Results

– Mean Log10 Reduction = 2.0 – 25% of HCWs achieved less than 1.1 Log10 reduction – Areas frequently not covered by ABHR included thumbs, finger tips & between fingers Widmer AF et al. ICHE 2004;25:207

Source: Widmer AF ICAAC 2005

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